Arya Shipra, Kim Sung In, Duwayri Yazan, Brewster Luke P, Veeraswamy Ravi, Salam Atef, Dodson Thomas F
Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga; Atlanta Veterans Affairs Medical Center, Decatur, Ga.
Emory University Rollins School of Public Health, Atlanta, Ga.
J Vasc Surg. 2015 Feb;61(2):324-31. doi: 10.1016/j.jvs.2014.08.115. Epub 2014 Oct 12.
Frailty, defined as a biologic syndrome of decreased reserve and resistance to stressors, has been linked to adverse outcomes after surgery. We evaluated the effect of frailty on 30-day mortality, morbidity, and failure to rescue (FTR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair.
Patients undergoing elective endovascular AAA repair (EVAR) or open AAA repair (OAR) were identified in the National Surgical Quality Improvement Program database for the years 2005 to 2012. Frailty was assessed using the modified frailty index (mFI) derived from the Canadian Study of Health and Aging (CSHA). The primary outcome was 30-day mortality, and secondary outcomes included 30-day morbidity and FTR. The effect of frailty on outcomes was assessed by multivariate regression analysis, adjusted for age, American Society of Anesthesiology (ASA) class, and significant comorbidities.
Of 23,207 patients, 339 (1.5% overall; 1.0% EVAR and 3.0% OAR) died ≤30 days of repair. One or more complications occurred in 2567 patients (11.2% overall; 7.8% EVAR and 22.1% OAR). Odds ratios (ORs) for mortality adjusted for age, ASA class, and other comorbidities in the group with the highest frailty score were 1.9 (95% confidence interval [CI], 1.2-3.0) after EVAR and 2.3 (95% CI, 1.4-3.7) after OAR. Similarly, compared with the least frail, the most frail patients were significantly more likely to experience severe (Clavien-Dindo class IV) complications after EVAR (OR, 1.7; 95% CI, 1.3-2.1) and OAR (OR, 1.8; 95%, CI, 1.5-2.1). There was also a higher FTR rate among frail patients, with 1.7-fold higher risk odds of mortality (95% CI, 1.2-2.5) in the highest tertile of frailty compared with the lowest when postoperative complications occurred.
Higher mFI, independent of other risk factors, is associated with higher mortality and morbidity in patients undergoing elective EVAR and OAR. The mortality in frail patients is further driven by FTR from postoperative complications. Preoperative recognition of frailty may serve as a useful adjunct for risk assessment.
衰弱被定义为一种储备能力下降和对应激源抵抗力降低的生物学综合征，与手术后的不良结局相关。我们评估了衰弱对接受择期腹主动脉瘤（AAA）修复术患者30天死亡率、发病率及未能挽救（FTR）情况的影响。
在国家外科质量改进计划数据库中确定2005年至2012年期间接受择期血管腔内AAA修复术（EVAR）或开放性AAA修复术（OAR）的患者。使用源自加拿大健康与老龄化研究（CSHA）的改良衰弱指数（mFI）评估衰弱情况。主要结局为30天死亡率，次要结局包括30天发病率和FTR。通过多因素回归分析评估衰弱对结局的影响，并对年龄、美国麻醉医师协会（ASA）分级及显著合并症进行校正。
23207例患者中，339例（总体1.5%；EVAR组1.0%，OAR组3.0%）在修复术后≤30天死亡。2567例患者发生了一种或多种并发症（总体11.2%；EVAR组7.8%，OAR组22.1%）。在调整年龄、ASA分级及其他合并症后，衰弱评分最高组的EVAR术后死亡比值比（OR）为1.9（95%置信区间[CI]，1.2 - 3.0），OAR术后为2.3（95%CI，1.4 - 3.7）。同样，与最不衰弱的患者相比，最衰弱的患者在EVAR（OR，1.7；95%CI，1.3 - 2.1）和OAR（OR，1.8；95%CI，1.5 - 2.1）术后发生严重（Clavien - DindoⅣ级）并发症的可能性显著更高。衰弱患者的FTR率也更高，术后发生并发症时，衰弱程度最高三分位数组的死亡风险比是最低三分位数组的1.7倍（95%CI，1.2 - 2.5）。
独立于其他危险因素之外，较高的mFI与接受择期EVAR和OAR的患者更高的死亡率和发病率相关。衰弱患者的死亡率因术后并发症导致的FTR而进一步升高。术前识别衰弱情况可能是一种有用的风险评估辅助手段。
